Table 1 Australia’s National Bowel Cancer Screening Program (NBCSP)

Australia is one of a few countries implementing a formal, government-funded, population-based CRC screening program. Others include the UK, Canada, France, Italy and Finland and Japan [5]. Following a pilot program in 2002–2004, the first phase of Australia’s National Bowel Cancer Screening program was rolled out in 2006 with free screening using FOBT offered to individuals turning 55 and 65 years of age. The second phase of the program began in July 2008 and expanded eligibility to all people turning 50, 55 or 65 years. The program targets only specific age groups due to limited funding and to ensure health services can cope with increased service demands [6]. However there are doubts about the evidence-base upon which these decisions have been made [7]. Eligible participants are identified through Medicare (Australia’s national health insurance scheme) enrolment and sent an invitation and FOBT screening kit to their home. After taking two consecutive samples of stool, individuals are required to return the screening kit by post to the laboratory using a reply paid envelope provided [8]. Participants and their nominated doctor are then notified of their result by mail recommendations made for follow-up if necessary. A bowel cancer screening register was established within Medicare to assist in follow-up of positive tests not undergoing colonoscopies, re-screening of participants, and to aid data collection, monitoring and evaluation [6]. The data obtained are collected via forms filled in by the individual, their GP, colonoscopist and others. Completion of forms is not compulsory; hence a large amount of information is incomplete or missing [9].

The screening test

The faecal occult blood test (FOBT) is a simple non-invasive self-screening test that detects small amounts of blood in the bowel motion. The FOBT is the only screening test for CRC where evidence from randomised control trials (RCT) has demonstrated a reduction in mortality, although the trials used the guaiac FOBT (gFOBT) as opposed to immunochemical FOBTs (iFOBT), the test used in Australia. A recently completed RCT using the iFOBT demonstrated increased detection and compliance, although long-term mortality benefits have yet to be demonstrated [10].

Targeting the Indigenous population

In 2005/2006 it was announced that Indigenous people could participate in the NBCSP from the age of 45 years due to their earlier onset of bowel cancer [11]. However, it is not clear whether FOBT kits are in fact being sent out to Indigenous people at this earlier age. Given that this would require Indigenous status to be reliably identified on Medicare enrolment records, a large proportion of at-risk Indigenous people are likely to be missing out on earlier screening.

Challenges and controversy surrounding the Program

The NBCSP has drawn much negative media attention which no doubt has influenced consumers’ opinions and created uncertainty regarding the legitimacy and quality of test results. It has been described as a ≤piecemeal’ program that is inadequately funded, lacking resources and effective communication strategies [12, 13]. In 2009, nearly half a million testing kits were recalled and the program was temporarily suspended for six months after an unusual decline in the number of positive test results, assumed to be due to faulty kits [7]. Testing resumed in November 2009 with a new kit that was initially distributed to re-screen those who received the faulty kits and led to significant delays in rollout of the program. The new kit is recommended for use only up to 30 degrees Celsius, creating potential problems for many regions, particularly in the north of Australia.

Funding and future of the Program

Initial funding for the Program was only secured up until June 2011 and the future of the program was uncertain for some time [12]. Substantial lobbying and advocacy by community groups and several organisations led to a Government announcement in July 2011 to continue ongoing funding of the program. In early May 2012, the Government committed to extending the program to those turning 60 years from 2013, and those turning 70 in 2015 [14]. However, until 2017 the program will remain as it is, allowing for once-off testing of the population, even though the mortality benefit associated with screening depends participation in regular screening [15]. According to the new announcement, full implementation including biennial screening as recommended by clinical guidelines and supported by research [3, 16], will be introduced in a phased process from 2017 for all Australians aged 50 to 74. Such a fully implemented program can save lives - potentially preventing up to 500 deaths per year, and would cost the Australian Government an additional $50 million per year [17].